Claims Customer Service Advocate II

Summary

Responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions.

PGBA is a subsidiary company of Blue Cross Blue Shield of South Carolina.

This position is full‑time (40 hours/week) Monday‑Friday in a typical office environment. Employees are required to have flexibility to work any 8‑hour shift scheduled during hours of 9AM‑6PM. Training will be Monday‑Friday 8:00AM‑4:30/5:00PM on site at the GPC Location for approximately 6–8 weeks. This role is located on site at 17 Technology Circle, Columbia SC. Hours will not change due to contractual obligations.

This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Blue Cross Blue Shield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara‑O’Hara Service Contract Act, employees are required to enroll in health insurance benefits regardless of other insurance coverage. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.

• Respond to written or telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
• Accurately document inquiries.
• Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
• Examine and process claims and/or non‑medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Ensure claims are processed according to established quality and production standards.
• Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines, and refer these to a lead or manager for resolution.
• Identify and promptly report or refer suspected fraudulent activities and system errors to the appropriate departments.

• Education: High School Diploma or equivalent.
• Experience: 1 year of experience including 1 year in claims/appeals processing, customer service, or other related support area, OR a bachelor’s degree in lieu of work experience.
• Skills and Abilities:
  • Good verbal and written communication skills.
  • Strong customer service skills.
  • Good spelling, punctuation and grammar skills.
  • Basic business math proficiency.
  • Ability to manage confidential or sensitive information with discretion.
• Software and Tools: Microsoft Office.

• Associate degree.
• 2 years of claims processing or call center experience.
• Knowledge of word processing, spreadsheet and database software.

• Subsidized health plans, dental and vision coverage.
• 401(k) retirement savings plan with company match.
• Life insurance.
• Paid Time Off.
• On‑site cafeterias and fitness centers in major locations.
• Wellness program and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Employee assistance program.
• Discounts to movies, theaters, zoos, theme parks and more.

Blue Cross Blue Shield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote…